Bethesda Memorial Hospital


About the Facility

CMS Certification Number (CCN)
10T002
Ownership Type
Non-profit
CMS Region
Atlanta
Certification Date
Address
2815 South Seacrest Blvd
Phone Number
(561) 737-7733

Facility Medical Condition Statistics

All other conditions
112
Brain disease or condition (non-traumatic)
46
Brain injury (traumatic)
13
Hip or femur fracture
138
Hip or knee replacement, amputation or other bone or joint condition
94
Nervous system disorder (excluding stroke)
54
Spinal cord disease or condition (non-traumatic)
13
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
95

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Catheter days
362
Predicted number of infections (B)
0.523
Number of infections reported (A)
1
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
563
Denominator
563
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.6
Denominator
504
Average observed change score
11.0
Change in patients ability to move around
Average risk-adjusted change score
27.9
Denominator
504
Average observed change score
29.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
218
Denominator
504
Facility rate
43.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
232
Denominator
504
Facility rate
46.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
563
Facility rate
0.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.023
SIR 95% confidence interval - upper limit
2.270
Comparative performance category
No Different than the National Benchmark
Patient days
6,689
Predicted number of infections (B)
2.173
Number of infections reported (A)
1
SIR (A/B)
0.460
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
475
Number of health care workers
524
Rate of flu vaccination
90.6
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
50
Number of eligible stays
603
Unadjusted potentially preventable readmission rate
8.29
Risk-standardized potentially preventable readmission rate (RSRR)
8.91
Lower limit of the 95% confidence interval on the RSRR
7.26
Upper limit of the 95% confidence interval on the RSRR
10.71
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
31
Number of eligible stays
654
Unadjusted potentially preventable readmission rate
4.74
Risk-standardized potentially preventable readmission rate (RSRR)
5.30
Lower limit of the 95% confidence interval on the RSRR
3.92
Upper limit of the 95% confidence interval on the RSRR
6.94
Comparative performance category
No Different than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
362
Number of eligible stays
517
Observed discharge to community rate
70.02
Risk-standardized discharge to community rate
67.58
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
64.01
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.94
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.98
Number of eligible episodes
651
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
558
Denominator
563
Facility rate
99.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
5
Denominator
563
Facility observed rate
0.9
Facility risk-adjusted rate
1.1
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
161
Number of health care workers
175
Rate of COVID-19 vaccination
92.0